Have you ever been convicted of a crime other than a simple misdemeanor?*

Yes

No

Do you have any physical or mental condition which would prevent you from performing any of the essential duties of the job for which you are applying?*

Yes

No

If yes, are you requesting that the company make any type of accommodation?

EDUCATION

Select highest year of school completed in each category

High School

College / University

Graduate School

High School

Name of School (city, state)

Major Studies

Did you graduate?

Yes

No

Cumulative GPA or grade Average

Degree / Major

Business, Trade or Correspondence

Name of School (city, state)

Major Studies

Did you graduate?

Yes

No

Cumulative GPA or grade Average

Degree / Major

College (undergraduate)

Name of School (city, state)

Major Studies

Did you graduate?

Yes

No

Cumulative GPA or grade Average

Degree / Major

College (graduate)

Name of School (city, state)

Major Studies

Did you graduate?

Yes

No

Cumulative GPA or grade Average

Degree / Major

Scholastic Honors, Scholarships, Assistantships, etc.

Certifications

Attending school now?

Yes

No

If so, where?

List subjects of special study or training

Foreign language proficiency

WORK HISTORY

Full name of employer

Address

CityState / Province / Region

Type of business

Position

Name of supervisor/telephone

Type

Full-time

Part-time

Temporary

From

To

Ending Salary

Reason for Leaving

Describe major responsibilities

Past Employer #2

Full name of employer

Address

CityState / Province / Region

Type of business

Position

Name of supervisor/telephone

Type

Full-time

Part-time

Temporary

From

To

Ending Salary

Reason for Leaving

Describe major responsibilities

BUSINESS / PROFESSIONAL REFERENCES

Reference #1

Name

Title

Company

Phone Number

Reference #2

Name

Title

Company

Phone Number

Reference #3

Name

Title

Company

Phone Number

Reference #4

Name

Title

Company

Phone Number

RESUME

Attach your resume
(.docx, .pdf, .odf)

Please read carefully!

“An applicant who is offered full or part time employment will be required as a condition of employment to participate and pass a drug screen to detect the use or presence of illegal substances as provided in company policy. I understand and agree that, if hired, my employment is at-will which means it is for an indefinite period of time and may be terminated by me or the company at any time with or without cause and without any advance notice regardless of the number of years of service with the company. I understand that this company has the right to investigate my driving record and past employment, education, and activities. I release from all liability all persons, companies and corporations supplying such information. I indemnify NEW Cooperative Inc. against any liability which might result from making such investigation. I understand that any false answer or statement or implications made by me in this application or other required documents may result in denial of employment or discharge.”

Agreement*

I agree

Signature*

Date*

Disclosure and Authorization For Release of Information

As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer report may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to, credit information reports, criminal history report and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are entitled to a copy of your Consumer Rights Under the Fair Credit Reporting Act.

Authorization and Release To Obtain Information

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit NEW Cooperative, Inc. to obtain a consumer report and/or an investigative consumer report which may include the following:

Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records.

I understand that an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

I agree that a copy of this authorization has the same effect as an original.

I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as NEW Cooperative, Inc. from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification.

I hereby authorize NEW Cooperative, Inc. to obtain and prepare an investigation consumer report as set forth above, as part of its investigation of my employment application. This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment.